Expert Critique

While the micro and macro-vascular complications of type 1 diabetes mellitus (T1DM) are well-established, there are a host of psychiatric co-morbidities associated with T1DM that are often overlooked. Furthermore, there is recent evidence that the offspring of patients with T1DM also have a higher risk for certain disorders; for example, the following article addresses the higher risk of developing ADHD amongst children of a parent with T1DM. The primary study reviewed in the article was a retrospective cohort study and therefore any association must be interpreted with caution and cannot prove causation. However, the authors of the article did account for multiple confounding variables and the sample size was rather large, making the association a compelling one. There may also be a link between a personal diagnosis of T1DM and developing ADHD, though as the article explains, this association is a weaker one. Nevertheless, cases in which the two conditions co-exist present a treatment challenge, particularly in young patients, and ideally multi-disciplinarily approach is available.

Full Critique

There is an abundance of research investigating the link between type 1 diabetes and the development of other associated conditions. It is well established that individuals with type 1 diabetes (T1D) are in fact at risk for development of other autoimmune conditions.

Additionally, individuals with T1D can be more prone to battling depression and anxiety which can undermine proper management and control. And, now a well-powered retrospective cohort study in Sweden suggests increased incidence of attention deficit hyperactivity disorder (ADHD) in the offspring of parents with T1D.

The study from the Center for Primary Health Care Research at Lund University in Sweden analyzed 15,615 children who had parents with type 1 diabetes. This cohort was then compared with a group of 1,380,829 young individuals who did not have type 1 diabetes in the family. The study discovered that after controlling for certain confounding variables, the offspring of T1D parents had a 29% increased risk of developing ADHD. Specifically, the risk for ADHD demonstrated a hazard ratio (HR) of 1.29 (95% CI 1.15-1.42). Additionally, maternal T1D was associated with a HR of 1.35 (95% CI 1.18-1.55) and paternal T1D with a HR of 1.20 (95% CI 1.03-1.41). However, the maternal compared with paternal risks were not statistically significant. It is important to note that the authors also state that further studies are needed to explore the underlying mechanisms.

Recognizing Attention Deficit Hyperactivity Disorder (ADHD)

Nonetheless, the retrospective cohort study is well-powered with a large sample size and thus largely suggests that there may in fact be a link between the incidence of ADHD in the offspring of parents with T1D. But first, the guidelines for diagnosis of ADHD are essential to review

Among the symptoms outlined in DSM-5 are:

A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.

Several inattentive or hyperactive-impulsive symptoms present prior to age 12 years.

Several inattentive or hyperactive-impulsive symptoms present in two or more settings (e.g. at home, school or work; with friends or relatives; in other activities).

Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder, and are not better explained by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

Potential Risk factors

Other potential risk factors were also described by the Lund University researchers and include low birth weight and the mother smoking, taking drugs, or drinking large quantities of alcohol during pregnancy. Boys are more likely than girls to be diagnosed with ADHD and the risk is increased if the condition exists in the family.

Is there a direct link between individuals with type 1 diabetes and the incidence of ADHD?

A study in Germany in 2014 aimed to analyze the prevalence of ADHD in children and adolescents with T1D. Initially 677, 587 children and adolescents age 0-18 years were analyzed. Of this group, 16,833 had received a diagnosis of ADHD (2.5%) and 3668 were treated for T1D. Of those with T1D, 153 children were also diagnosed with ADHD or 4.2%. This suggests that children with type 1 diabetes are more frequently also diagnosed with ADHD compared with children without diabetes. However, as the authors note it is likely that children with T1D are more likely to be evaluated by healthcare professionals and their ADHD is thus identified.

Learning point for the clinician

Still, it is important to consider a potential link as undiagnosed ADHD may further complicate appropriate management of T1D. This personal account of an individual with T1D and ADHD outlines the difficulties managing of both conditions. The biggest take away for clinicians is to understand that poor glucose management may not always be directly derived from nonadherence or medication failure for T1D itself. Complications may arise from other uncontrolled conditions such as, in this case, ADHD or, as referenced earlier depression, anxiety, or other autoimmune conditions.

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